A. DunnGalvin

Anaphylaxis: guidelines from the European Academy of Allergy and Clinical Immunology

Anaphylaxis is a clinical emergency, and all healthcare professionals should be familiar with its recognition and acute and ongoing management. These guidelines have been prepared by the European Academy of Allergy and Clinical Immunology (EAACI) Taskforce on Anaphylaxis. They aim to provide evidence‐based recommendations for the recognition, risk factor assessment, and the management of patients who are at risk of, are experiencing, or have experienced anaphylaxis. While the primary audience is allergists, these guidelines are also relevant to all other healthcare professionals. The development of these guidelines has been underpinned by two systematic reviews of the literature, both on the epidemiology and on clinical management of anaphylaxis. Anaphylaxis is a potentially life‐threatening condition whose clinical diagnosis is based on recognition of a constellation of presenting features. First‐line treatment for anaphylaxis is intramuscular adrenaline. Useful second‐line interventions may include removing the trigger where possible, calling for help, correct positioning of the patient, high‐flow oxygen, intravenous fluids, inhaled short‐acting bronchodilators, and nebulized adrenaline. Discharge arrangements should involve an assessment of the risk of further reactions, a management plan with an anaphylaxis emergency action plan, and, where appropriate, prescribing an adrenaline auto‐injector. If an adrenaline auto‐injector is prescribed, education on when and how to use the device should be provided. Specialist follow‐up is essential to investigate possible triggers, to perform a comprehensive risk assessment, and to prevent future episodes by developing personalized risk reduction strategies including, where possible, commencing allergen immunotherapy. Training for the patient and all caregivers is essential. There are still many gaps in the evidence base for anaphylaxis.

Food allergy QoL questionnaire for children aged 0–12 years: content, construct, and cross-cultural validity

Background To date, there is no food allergy‐specific questionnaire that allows parents to report childrens health‐related QoL (HRQL) from the childs perspective.

Health-related quality of life of food allergic patients: comparison with the general population and other diseases

To cite this article: Flokstra‐de Blok BMJ, Dubois AEJ, Vlieg‐Boerstra BJ, Oude Elberink JNG, Raat H, DunnGalvin A, Hourihane JO’B, Duiverman EJ. Health‐related quality of life of food allergic patients: comparison with the general population and other diseases. Allergy 2010; 65: 238–244.

Development and validation of a self-administered Food Allergy Quality of Life Questionnaire for children

Background Having a food allergy may affect health‐related quality of life (HRQL). Currently, no validated, self‐administered, disease‐specific HRQL questionnaire exists for children with food allergy.

Skin barrier dysfunction measured by transepidermal water loss at 2 days and 2 months predates and predicts atopic dermatitis at 1 year

Background Loss-of-function mutations in the skin barrier protein filaggrin (FLG) are a major risk for atopic dermatitis (AD). The pathogenic sequence of disturbances in skin barrier function before or during the early development of AD is not fully understood. A more detailed understanding of these events is needed to develop a clearer picture of disease pathogenesis. A robust, noninvasive test to identify babies at high risk of AD would be important in planning early intervention and/or prevention studies. Objectives To ascertain whether a noninvasive measurement of skin barrier function at day 2 after birth and at 2 months predicts the development of AD at 1 year. Furthermore, to determine whether increases in transepidermal water loss (TEWL) predate the development of clinical AD. Methods A total of 1903 infants were enrolled in the Cork Babies After Scope: Evaluating the Longitudinal Impact Using Neurological and Nutritional Endpoints Birth Cohort study from July 2009 to October 2011. Measurements of TEWL were made at birth (day 2) and at 2 and 6 months. The presence of AD was ascertained at 6 and 12 months, and disease severity was assessed by using the SCORing Atopic Dermatitis clinical tool at 6 months and by using both the SCORing Atopic Dermatitis clinical tool and Nottingham Severity Score at 12 months. A total of 1300 infants were genotyped for FLG mutations. Results At 6 months, 18.7% of the children had AD, and at 12 months, 15.53%. In a logistic regression model, day 2 upper quartile TEWL measurement was significantly predictive of AD at 12 months (area under the receiver operating characteristic curve, 0.81; P < .05). Lowest quartile day 2 TEWL was protective against AD at 12 months. An upper quartile 2 month TEWL was also strongly predictive of AD at 12 months (area under the receiver operating characteristic curve, 0.84; P < .05). At both ages, this effect was independent of parental atopy, FLG status, or report of an itchy flexural rash at 2 months. Associations were increased when parental atopy status or child FLG mutation status was added into the linear regression model. Conclusions Impairment of skin barrier function at birth and at 2 months precedes clinical AD. In addition to providing important mechanistic insights into disease pathogenesis, these findings have implications for the optimal timing of interventions for the prevention of AD.

Highly accurate prediction of food challenge outcome using routinely available clinical data

BACKGROUND Serum specific IgE or skin prick tests are less useful at levels below accepted decision points. OBJECTIVES We sought to develop and validate a model to predict food challenge outcome by using routinely collected data in a diverse sample of children considered suitable for food challenge. METHODS The proto-algorithm was generated by using a limited data set from 1 service (phase 1). We retrospectively applied, evaluated, and modified the initial model by using an extended data set in another center (phase 2). Finally, we prospectively validated the model in a blind study in a further group of children undergoing food challenge for peanut, milk, or egg in the second center (phase 3). Allergen-specific models were developed for peanut, egg, and milk. RESULTS Phase 1 (N = 429) identified 5 clinical factors associated with diagnosis of food allergy by food challenge. In phase 2 (N = 289), we examined the predictive ability of 6 clinical factors: skin prick test, serum specific IgE, total IgE minus serum specific IgE, symptoms, sex, and age. In phase 3 (N = 70), 97% of cases were accurately predicted as positive and 94% as negative. Our model showed an advantage in clinical prediction compared with serum specific IgE only, skin prick test only, and serum specific IgE and skin prick test (92% accuracy vs 57%, and 81%, respectively). CONCLUSION Our findings have implications for the improved delivery of food allergy-related health care, enhanced food allergy-related quality of life, and economized use of health service resources by decreasing the number of food challenges performed.

Longitudinal validity and responsiveness of the Food Allergy Quality of Life Questionnaire - Parent Form in children 0-12 years following positive and negative food challenges.

Background There are no published studies of longitudinal health‐related quality of life (HRQL) assessments of food‐allergic children using a disease‐specific measure.

Management of anaphylaxis: a systematic review

To establish the effectiveness of interventions for the acute and long‐term management of anaphylaxis, seven databases were searched for systematic reviews, randomized controlled trials, quasi‐randomized controlled trials, controlled clinical trials, controlled before–after studies and interrupted time series and – only in relation to adrenaline – case series investigating the effectiveness of interventions in managing anaphylaxis. Fifty‐five studies satisfied the inclusion criteria. We found no robust studies investigating the effectiveness of adrenaline (epinephrine), H1‐antihistamines, systemic glucocorticosteroids or methylxanthines to manage anaphylaxis. There was evidence regarding the optimum route, site and dose of administration of adrenaline from trials studying people with a history of anaphylaxis. This suggested that administration of intramuscular adrenaline into the middle of vastus lateralis muscle is the optimum treatment. Furthermore, fatality register studies have suggested that a failure or delay in administration of adrenaline may increase the risk of death. The main long‐term management interventions studied were anaphylaxis management plans and allergen‐specific immunotherapy. Management plans may reduce the risk of further reactions, but these studies were at high risk of bias. Venom immunotherapy may reduce the incidence of systemic reactions in those with a history of venom‐triggered anaphylaxis.

A framework for measuring the social impact of food allergy across Europe: a Europrevall state of the art paper

This state of the art paper has been developed through EuroPrevall, a European multicentre research project funded by the European Union which aims to improve quality of life for food allergic individuals. Food allergy (whether clinically diagnosed or self‐perceived) represents a major health issue in Western societies and may have a considerably greater impact on society than was previously believed. However, the social impact of food allergy has never been systematically investigated using validated instruments. Combining the information from studies on health‐related quality of life (HRQoL) with epidemiological data on prevalence will ultimately give some indication of the magnitude of the social impact of food allergy in Europe. HRQoL can be assessed with disease‐specific questionnaires, which are being developed in EuroPrevall. These instruments will be used to identify HRQoL problems associated with food allergy, and to assess the effectiveness of interventions and to guide the development of regulatory policies.

Developmental pathways in food allergy: a new theoretical framework.

Background:  To date, there is no model of psychosocial development based on empirical food allergy (FA) research. This limits the ability of clinicians, researchers and policy‐makers to predict and evaluate the real impact of FA on the child, with implications for prevention, treatment, intervention and health policy.